Reaching rural areas by incorporating telemedicine, public health research, policy changes and specific programs
by Celia Spell
While rural areas offer open spaces, bucolic views, a sense of community and less crowded places, they do not offer easy access to health care.
Fourteen percent of the U.S. population lives in rural communities, according to the National Institutes of Health, but that number nearly doubles when you look at South Carolina alone. With over 27% of South Carolina residents living in rural areas, MUSC has made reaching those areas a top priority.
Amy Martin, DrPH, MSPH, is an associate professor and director for the division of population health at the James B. Edwards College of Dental Medicine at MUSC. She points to primary care as a common access point to oral health care in rural parts of the state. There may not be a dentist near a patient’s town, but there is more likely to be a primary care physician. They’re the first stop, but it’s important to know what care they can reasonably take on.
“A lot of our research is focused on two things,” she said. “How do we support primary care and how do we optimize what they can do within their scope of practice around addressing the oral health needs of priority patients?”
Priority patients to Martin are those that are least covered in dental school and thus will also be even harder for primary care physicians or a rural general dentist to be prepared for. Children under 5 years of age, pregnant women, those living with chronic disease like diabetes or HIV, and those with memory loss disorder are just a few examples of people who might have unique dental needs beyond the scope of their doctor.
With a research focus on systems redesign, Martin also studies how primary care and rural general dentistry can work together in collaborative referral relationship.
Patients undergoing chemotherapy or awaiting an organ transplant, for example, are complex cases for whom oral health is critically important. “If these patients have unaddressed oral health needs, they can develop a systemic infection,” she said. “And with an infection, patients are unable to continue chemotherapy or receive an organ donation.”
MUSC’s dental school provides training and coaching aimed at quality improvement techniques to reach rural clinics that handle these patients. To reach young children, Martin says that MUSC – with the help of a Duke Endowment Grant – also focuses on school-based oral health care in both North and South Carolina.
“Why are we putting so much money and investments into places where there are smaller populations?” she asks. “Because we need these rural areas; they are the backbone of our economy. We cannot extract fuel, we cannot grow food – there’s so much we can’t do without them. And they need health care.”
Policies are still being developed around telemedicine for dentistry, but MUSC offers one of the biggest telehealth centers in the country.
James McElligott, M.D., MSCR, is the executive medical director for the MUSC Center of Telehealth, and he says the center supports over 40 hospitals in the state. In addition to consultative services, MUSC hospitalists partner with nurse practitioners to provide direct rounding services, which allows those hospitals and clinics to keep patients local. “It gives them specialty access,” he said. “And it lowers the cost for hospitals.”
One option for health care providers in rural areas is through the Center for Telehealth’s service extension, which puts telehealth tools in place for everyone, at no cost to the clinic. Credit: Sarah Pack
Another option for health care providers in rural areas is through the Center for Telehealth’s service extension, which puts telehealth tools in place for everyone to use through video conferencing that connects patients directly to a long-distance provider. And while use in this area exploded in 2020, McElligott says it’s still more commonly used in urban settings than rural ones, even though rural areas have a greater need.
The reasons behind the discrepancy are still unknown.
“There’s an aspect to it that includes digital literacy and connectivity issues,” he said. “There is often less access to internet in rural areas, and with that less familiarity, but there could be issues with Medicaid support or distrust in health care in general.”
The virtual health care platform is still used in every county in the state, but McElligott thinks there’s an opportunity for more widespread use in rural areas, and he wants to find more ways to embed telehealth systems in those communities through engagements, referrals and promo codes.
And since the telehealth program is state funded, hospitals and clinics across South Carolina can use the technology platform at no cost. Any clinic just needs to submit a request through MUSC regardless of their usage of MUSC-specific health care services.
“We’re moving the needle,” McEilligott said. “But until we can distribute health care equally, communication tools are going to be really important. And that’s what telehealth is.”
Sarah Miller, RN, Ph.D., is a nurse scientist and associate professor with the MUSC College of Nursing, and she works with patients in rural areas with chronic obstructive pulmonary disease, or COPD. COPD refers to a group of diseases that block airflow and make it hard for people to breathe.
Studies show that rates of COPD are higher in rural areas than in urban ones, and Miller says that industry plays a big role. “Increased exposure to environmental toxins and air flow pollutants in the agriculture industry, for example, have been known to increase your risk of developing lung disease or exacerbating it,” she said. “And those kinds of industries are more common in rural areas.”
With more patients with COPD and fewer specialists close to them, Miller focuses on teaching patients the information they need to know to care for themselves at home when possible. Working with a software company called PulManage, Miller and her team help patients with COPD track their lung function with a mobile spirometry device. It allows both the patients and physicians to monitor their progress over time. Providers can look at this history and develop a personalized treatment plan for their patients, even if they aren’t in their area.
“Historically, one of our priorities at the College of Nursing has been to empower our patients to self-manage,” Miller said. “With COPD in particular, people often feel powerless when they can’t control their breathing. And that’s a terrible feeling. Being able to take ownership of their care and play an active role in their own disease management can really give some of that power back.”
A new function that Miller hopes to roll out soon is the ability to have unsynchronized provider appointments where patients can upload a video of them breathing into their spirometry device, and the provider can look at it later in the day and provide feedback rather than scheduling a live appointment. This freedom would give patients and providers another way of being available long distance.
Miller is happy that MUSC is making a concentrated effort in reaching rural areas. “It’s important that we reach people living in rural communities to provide similar equitable resources to those living in urban areas.”
Marvella Ford, Ph.D., a professor in the Department of Public Health Sciences at MUSC and the associate director for population sciences at Hollings Cancer Center, reaches patients with a vaccination van. With funding from both Healthy Me-Healthy SC (HMHSC) and Hollings, providers at MUSC can take vaccines for the human papillomavirus (HPV) directly to patients in rural areas.
Marvella Ford, Ph.D. (second from left), reaches patients with a vaccination van that can take HPV vaccines directly to patients in rural areas. Credit: Sarah Pack
“If you had a vaccine that could prevent breast cancer, prostate cancer or lung cancer, wouldn’t everyone take it?” she said. “We say this HPV vaccine is cancer prevention because it is.” HPV is linked to six different types of cancer according to the Centers for Disease Control and Prevention.
Through the HMHSC clinics and by incorporating school nurses in school districts across the state, the program provides HPV and other childhood immunizations to children between the ages of 9 and 18.
In 2016, South Carolina ranked last in the U.S. for rates of vaccination against HPV. By 2019, Ford says rates were on par with the rest of the country, and most recently, rates in South Carolina were actually higher than in the rest of the country.
Ford says teamwork and collaboration are at the heart of this improvement. “That’s what I love about working in South Carolina,” she said. “We’re a small state, and we don’t have a lot of resources, but we all come together from different organizations around a common cause and work together to get the job done. And you don’t see that in every state.”
Between teamwork, increased communication efforts and telehealth opportunities and increased education both in clinics and to patients, MUSC is reaching communities across the state with limited access to health care. According to McElligott, MUSC is in a unique position to grow its efforts to care for rural areas. “We have the need, we have the resources, and we have the capacity to research it.”
And Miller says empowering patients to take control of their own health is an important way to increase connection and improve care in the state.
Progressnotes Spring 2023